Everyone sees learning from mistakes as a requirement within Knowledge Management. But how do you set the right culture so this is made possible?

Effective lesson learning requires learning from all events, positive and negative. People need to feel free to discuss learning from mistakes and failures, and often talk about the "no-blame culture" as a way to achieve this.

However sometimes blame is needed. When people wilfully and recklessly flout rules and guidelines, knowing that they are doing a wrong or stupid thing, then they deserve blame, and not to blame them means others see that you can get away with stupid behaviour. Therefore the no-blame culture is not realistic.

Instead we need the Just Culture, which is where front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. In other words, people shouold not be blamed for making wrong decisions when the organisation had not provided them with enough knowledge to make the right decisions.

Last week I blogged about SKYbrary, the online wiki for sharing knowledge on aviation safety. Safety is such a concern for this industry given the potentially fatal consequences of mistakes and failures, that much thought has been given to the correct cultural approach to learning. It is therefore no surprise to find, within SKYbrary, a toolkit on implementing and applying the Just Culture.

This toolkit was developed by Job Brüggen, Safety manager at Air Traffic Control the Netherlands and Patrick Kools of GoGen - Beyond Rules. For provision of feedback to authors and further information about using the application go here.

The toolkit recognises 8 levels of behaviour in terms of safety issues, and provides guidance for dealing for each one, as follows (more details available from the toolkit)

Exceptionally skillful handling of a safety situation. A person really excelled in probably a difficult situation. Recognising exceptional behaviour is an important element in a just culture, but it is important to be clear about WHAT you are rewarding and HOW you reward it

By thoroughly understanding how the system works, a person was able to suggest an important improvement to the operations itself or to the safety management system. Improving the system effectively demonstrates a high level of skill. This should be recognised and rewarded, not just for the individual but also because sets a model for other people as how they can apply their expertise and insight to help everybody improve.

People took action to help others understand and operate the system better. This could be based on a self-experienced incident or based on a known events in the organisation or elsewhere. Becoming a teacher, sharing lessons learned, is not only a major milestone in the development of a professional but is also a significant contribution to a safety culture. So, teachers should be recognised and rewarded.

The person was demonstrating skills working the system as it is known. By the book, intervening where needed. He knows his business! Working well with the system should not be trivialised. Recognising and rewarding this will establish this way of working as a desirable state. If you do not recognise or reward it, people will see working with the system as dull, boring and unattractive.

Somebody made an error. These can be "slips" or "lapses", where an action was forgotten or the action was unintentional. Or it could be a "mistake", in which the wrong procedure was applied (action was intentional, follow up was not). The toolkit has a number of tests to follow depending on whether this was the first time it happened, whether the same person did it before, or whether everybody makes the same mistake. One of the tests is the Substitution test - "would a different person, in the same set of circumstances, make the same mistake?" If the answer is Yes, then then you cannot blame this person, but should rather seek systemic issues.

A rule or procedure was not followed. Either the rule was not not known, or the rule was too ambiguous or complicated to understand properly. Again you need more detailed investigation, and the application of various tests. If, for example, "everyone ignores this rule" then either the rule is broken, or the culture, and you need to fix one or both.

Although the person knew about the rule and the rule in principle was workable, he or she decided that this was not applicable. Either this was done to help the company or client, or this could be done because of "personal optimisation". Again you have more tests to do before you know whether to blame the person or fix the system.

Person knew there was a rule and person knew it was not followed, but that suited him or her just fine. Also known as "recklessness". Make sure you have checked out the Substitution test. If the answer to this is No, then you are perfectly entitled to blame the individual.

The toolkit shows us that assigning praise and blame needs to be done carefully, that in many cases the person made the mistakein all innocence because of lack of knowledge, but that there are cases where blame is appropriate.

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Nick Milton

I am a director for Knoco, the international firm of knowledge management consultants, offering a range of knowledge management services, including knowledge management strategy, knowledge management framework development, and knowledge management implementation services.
I also have an interest in Lessons Learned